CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2009 ending 09/30/2009 Date of Report:11/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 23 8.50 314.50 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 27 28.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 53 43.25 1600.25 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 93.50 3459.50 37.00
TCON-TCON-TRANSITION CONFERENCE 2 2.00 0.00 0.00
Subtotal (Total Children Is Unduplicated) 58 175.25 5374.25 30.67
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.17 12.72 74.82
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 14 25.93 1438.90 55.49
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.00 450.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.00 450.00 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 21.93 1216.89 55.49
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.08 755.64 74.96
Subtotal (Total Children Is Unduplicated) 18 70.11 4324.15 61.68
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EI Services,Class #03
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 29 2245.00 1122.50 0.50
Subtotal (Total Children Is Unduplicated) 29 2245.00 1122.50 0.50
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Total 2490.36 10820.90 4.35
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Number of Children (Unduplicated) With at Least One Service 58
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 127 1047.25 3865.25 3865.25
212 1443.11 6955.65 0.00
Other 0 0.00 0.00 0.00
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Total 339 2490.36 10820.90 3865.25